Several techniques have been tested to prevent chemotherapy‐induced hair loss, the first being scalp tourniquets. These were used to minimize the contact the drug had with the hair follicles by occluding, using pressure, the superficial blood vessels supplying the scalp (Maxwell [149]). However, while some investigators found scalp tourniquets effective, others reported this method to be time‐consuming, uncomfortable or ineffective (Parker [187]). Research findings indicate that scalp hypothermia (cooling) may be simpler, less traumatic and more effective as a means of preventing alopecia when compared with the scalp tourniquet (David and Speechley [39]).

It has been documented that men and women experience similar concerns about body image when they have experienced chemotherapy‐induced hair loss, although women tended to speak about hair loss from the head and face (above the eyeline) while men spoke of losing hair from wider body surfaces (Hilton et al. [99]). Healthcare professionals must therefore be mindful that scalp cooling should be offered to patients as determined by the chemotherapy regimen and not the gender of the patient (Hilton et al. [99]).

In a study in which patients receiving chemotherapy for breast cancer who underwent scalp cooling were given questionnaires to complete before chemotherapy, after 3 weeks of treatment and 6 months after completion, the burden of scalp cooling was rated as low, suggesting that nursing staff must be aware of how distressing the matter of hair loss can be for patients, and scalp cooling should be offered wherever possible (Mols et al. [157]). Patients have been shown to be satisfied with scalp cooling when they experienced little hair loss and felt that it had been successful; where it was not 100% successful it still reduced the patient's need to wear a wig or head covering (van den Hurk [255]). Physicians tend to underestimate the impact of hair loss on patients so it may be up to the nurse to provide information on scalp cooling (Mulders et al. [161], Rosman [211]).

Scalp cooling is a method of preventing chemotherapy‐induced alopecia. It works in three ways (Batchelor [9], Bulow et al. [23]):

The rationale is based on characteristics of hair growth, the effect of cytotoxic drugs on hair follicles, physiological changes in scalp circulation and pharmacokinetics (Keller and Blausey [122]). Ninety percent of all scalp hair is in an active phase of growth, characterized by significant mitotic activity; this means the hair bulb is especially sensitive to chemotherapeutic agents (Parker [187]). Scalp hypothermia produces changes in the scalp circulation by causing vasoconstriction of superficial vessels. Decreased blood flow to the scalp reduces the amount of the drug reaching the hair follicles and thus minimizes damage to the scalp hair (Kennedy et al. [124], Parker [187]). Its success is also related to the metabolic effects of cooling, that is, slowing the metabolic rate (Bulow et al. [23]), and it also appears that the degree of hair loss is temperature dependent.

In order to prevent alopecia, the temperature of the scalp must be reduced to at least 24°C but preferably 22°C (Ekwall et al. [68], Gregory et al. [89]). Caps have to be kept in a freezer in order to reach temperatures of −18 to −20°C (Anderson et al. [5], Giaccone et al. [84], Kennedy et al. [124]). Then, when the cap is placed on the head, the scalp temperature will drop from 37°C to 23–24°C within the first 15 minutes (Guy et al. [92], Tollenaar et al. [245]). For this reason a preinjection scalp cooling time of 20–30 minutes is said to be required (Anderson et al. [5], Giaccone et al. [84], Kennedy et al. [124], Middleton et al. [156], Robinson et al. [204], Satterwhite and Zimm [217]). Janssen ([116]) studied the link between heat transfer in the human head and the transport of doxorubicin. This led to the development of a population‐based computational model for scalp cooling which included doses of doxorubicin of 60–70 mg, lowering skin temperature to 17–18°C, leaving the cap on for the total infusion time plus 1 hour and having a haircut to reduce thermal resistance between head and cap, all of which provided the most effective scalp cooling. Daanen et al. ([38]) found that slight cooling of patients with an elevated body temperature during scalp cooling contributed to the decrease in scalp temperatures and may improve the prevention of hair loss.

Scalp cooling has been used in an attempt to reduce hair loss with palliative whole‐brain radiotherapy. However, a pilot study (Shah et al. [231]) found that all patients still lost their hair and there was evidence that the cold cap application increased the dose of radiotherapy to the scalp; this is supported by van den Hurk et al. ([258]).

There have also been biological methods of preventing hair loss which have focused on promoting hair growth or protecting the hair follicles (Batchelor [9]). For example:

The effectiveness of scalp cooling has been demonstrated satisfactorily with doxorubicin, epirubicin, docetaxel and paclitaxel (Cigler et al. [33], Dean et al. [41], Katsimbri et al. [119], Lemenager et al. [134], Robinson et al. [204], van den Hurk et al. [253]). Patients receiving other cytotoxic drugs that may cause alopecia, such as vindesine and vincristine, have undergone the procedure, although there are insufficient data to evaluate its effectiveness with these drugs.

Doxorubicin is commonly used in cancer chemotherapy and has a uniquely short half‐life of approximately 30 minutes (compared with other drugs such as cyclophosphamide, which has a plasma half‐life of over 6 hours) (Priestman [197]). This factor makes prophylactic scalp cooling feasible because it need only be utilized during peak plasma levels (Cline [34]). This is particularly important because doxorubicin results in a consistently high incidence of alopecia (80–90% of all patients), often leading to total hair loss (Dean et al. [42]). The involvement of doxorubicin, whether used alone or in combination, is a feature of most of the reported scalp‐cooling studies. In some studies there was less success in maintaining hair with increasing doses of doxorubicin and/or liver metastases (David and Speechley [39], Dean et al. [42]), but this may be resolved by extending the time the cap remains in place following chemotherapy administration.

Scalp cooling has also been used during the administration of epirubicin, as a single agent, with good results (Robinson et al. [204]), although doses may influence outcomes (Adams et al. [1]). Subsequent studies have investigated combination regimens containing epirubicin and other drugs such as cyclophosphamide and 5‐FU, with results of mild to moderate hair loss. However, when intravenous cyclophosphamide is added to anthracycline, the success rate is reduced from 80% of patients keeping most of their hair to about 50–60% of patients (David and Speechley [39], Middleton et al. [156]). Some authors have therefore concluded that, when combinations of cyclophosphamide and anthracyclines are given, scalp cooling has no place at all (Tollenaar et al. [245]). The group of drugs known as the taxanes also has the unfortunate side‐effect of total alopecia; however, there is now evidence that scalp cooling in patients receiving docetaxel and paclitaxel can prevent complete hair loss (Betticher et al. [13], Katsimbri et al. [119], Komen et al. [127], Lemenager et al. [134], [135], Macduff et al. [143], van den Hurk et al. [253]).

Recommended cooling times have varied between studies and manufacturers. The common times are 15–30 minutes pre chemotherapy and then 45 minutes to 1 hour post anthracycline chemotherapy and 30–45 minutes post docetaxel administration (van den Hurk et al. [253]).

Scalp cooling requires the consultant's permission as the procedure may protect micrometastases in the scalp from chemotherapy, especially where there is the possibility of circulating cancer cells, for example in cases of leukaemia and lymphoma (Witman et al. [273]). Despite this, scalp cooling has been used successfully in patients with relapsed lymphoma (Purohit [199]). Dean et al. ([42]), drawing on evidence from 7800 women with breast cancer, found that only two experienced recurrence of disease on the scalp, suggesting that the risk of scalp metastases was minimal. They concluded that scalp cooling should not be contraindicated and could be used routinely with a wide variety of solid tumours. Nevertheless, patients with advanced metastatic disease have been found to develop scalp metastases during scalp cooling and Middleton et al. ([156]) argued strongly against the use of scalp cooling in this group. Other studies have found no scalp metastases at follow‐up (Ron et al. [209]). Lemieux et al. ([136]) found the incidence of scalp metastases was low and no case presented as an isolated site of relapse. However, the potential risk of scalp metastases, albeit remote, should be addressed and demands discussion by healthcare professionals and patients (Batchelor [9], Peck et al. [188]).

The issues relating to scalp metastases are controversial (Serrurier et al. [228]). This dilemma, along with the media coverage regarding preventive measures for chemotherapy‐induced alopecia (Carr [28], Kendell [123]), has led some practitioners to question whether scalp cooling should be offered. However, Lemieux et al. ([137]) found no impact on overall survival in women with breast cancer who had received scalp cooling, and van den Hurk et al. ([256]) showed the incidence of scalp skin metastases to be very low with no difference between those who had scalp cooling (0.04%) and those did not (0.03–3%).

Patients have highlighted how they feel about hair loss (Carr [28]) and the need to provide more comfortable and effective scalp cooling in all cancer units and centres (Wilson [271]). In addition, an extensive review of the literature concluded that scalp cooling was effective and should be offered to all patients for whom it was appropriate (Batchelor [9], Crowe et al. [37], van den Hurk et al. [257]). This was supported by the views of many nurses who felt that the use of scalp cooling with chemotherapy protocols that are associated with hair loss can effectively prevent alopecia and result in improved quality of life for patients (Lemenager [133], Young [278]). Patients also feel it is worthwhile to undergo scalp cooling regardless of how successful it is (Dougherty [58]). However, although scalp cooling contributes to well‐being in patients in whom it is successful, it can cause additional distress when patients lose their hair despite scalp cooling and so additional support may be required for those patients in whom scalp cooling is not successful (van den Hurk et al. [252]).

The success of all these methods of preventing hair loss varies and the amount of hair loss experienced by the patient is dependent on many factors.

Patients must give consent for the procedure but must first be fully informed about the nature and length of the procedure, the chances of success and, where appropriate, the risk of scalp metastases (Peck et al. [188]). Scalp cooling can be a long and uncomfortable procedure and should not be offered unless it is beneficial or the patient insists on undergoing the procedure. Peerbooms et al. ([189]) found that not all patients are offered scalp cooling due to doubts from healthcare professionals regarding its efficacy and safety. Patients must also be informed that they may discontinue the procedure at any time if they find it too physically or psychologically traumatic (Tierney [242]) or if they fail to retain hair.

Research shows that scalp cooling can be very distressing (Tierney [243]), although patients still find it a worthwhile procedure to undergo regardless of whether it is successful and many would have it again if necessary (Dougherty [54], [153]). It has also been shown that the severity and distress associated with hair loss may be less for those who use scalp cooling (Protiere et al. [198]).

Most of the studies that used an ice cap method of scalp cooling used a ‘home‐made’ or a commercial cap (Anderson et al. [5], David and Speechley [39], Dean et al. [42], Lemenager et al. [135]).

It is important to ensure that if a patient fails to retain hair or decides not to undergo scalp cooling, adequate time is spent helping the patient to adapt to the hair loss physically, psychologically and socially. It is recommended that nursing interventions be directed towards helping the patient and family to adapt to alopecia by using patient education, available resources and supportive listening (Pickard‐Holley [191]). This can be partly achieved by ensuring that the patient sees the surgical appliance officer as soon as possible, to obtain a wig that can be matched to the patient's desired hair style and colour.

Advice can be given on hair care such as the type of shampoo. There is a misconception that a mild shampoo such as baby shampoo is best, but this kind of shampoo is alkaline and it is recommended that a neutral pH shampoo be used (Dougherty [56], [58]). Using a wide‐toothed comb can prevent pulling on hair but the patient should not be afraid to comb their hair daily (Dougherty [58]). Patients should be advised to avoid anything that can dry out their hair such as using hair dryers on a hot setting, curlers and so on, or using chemicals such as perming lotions or hair dyes, and they should seek advice from a hairdresser. Finally, the patient should be given advice about the use of head coverings such as hats, turbans and scarves. All verbal information should be reinforced with a hair care information booklet (Batchelor [9], Pickard‐Holley [191]).